Building and Environment 237 (2023) 110324

Contents lists available at ScienceDirect

Building and Environment

journal homepage: www.elsevier.com/locate/buildenv

Risk of heatstroke in healthy elderly during heatwaves: A thermoregulatory

modeling study
Yinping Ou a, 1, Faming Wang b, 1, Jinping Zhao c, Qihong Deng d, *
a
School of Energy Science and Engineering, Central South University, Changsha, China
b
Division Animal and Human Health Engineering, Department of Biosystems (BIOSYST), KU Leuven, Kasteelpark Arenberg 30, Leuven, 3001, Belgium
c
School of Civil Engineering, Central South University of Forestry and Technology, Changsha, China
d
School of Public Health, Zhengzhou University, Zhengzhou, China

A R T I C L E I N F O A B S T R A C T

Keywords: Background: The frequency of temperature extremes is rising due to global warming. During heatwaves, the older
Elderly adults are more likely to experience heat-related illnesses due to impaired sweating and cardiovascular functions.
Core temperature Few existing studies have systematically examined the healthy elderly’s survival time and heatstroke/hyper­
Thermoregulation
thermia prevention measures during prolonged heatwaves.
Survival time
Heatstroke prevention
Objectives: We aimed to systematically examine the core temperature responses of elderly during prolonged
heatwaves and to predict survival time for the elderly using the modified Stolwijk thermoregulatory model.
Methods: The Stolwijk thermoregulatory model was modified to account for sweating and vasodilation alterations
in the elderly during exposure to high temperatures. The model was then used to study the influence of envi­
ronmental conditions on core temperature responses during the onset of classic heatstroke (Tcore =
40.5–40.6 ◦ C) and to estimate survival time.
Results: Core temperature increases in three distinct stages under intense heat stress: an initial stage for ther­
moregulatory equilibrium alignment, a thermoregulatory steady-state, and a last rapid progression due to
uncompensable heat stress resulting from dehydration. At the third stage, dehydration led to a fatal classic
heatstroke. The increased air temperature and relative humidity shortened the survival duration.
Conclusions: The extended thermoregulation model was able to predict the core temperature responses of healthy
elderly individuals exposed to extreme heat with reasonable accuracy (±0.3 ◦ C). Furthermore, the model can be
used to predict survival time and aid in the selection of efficient heatstroke prevention measures suited to the
elderly.

sweating function as well as cardiovascular function (reduced blood

1. Introduction flow and cardiac output, etc.). Further, older persons are less thermo­
sensitive to environmental changes and less efficient in responding to
As global warming continues unabated, there will be increasingly cold and heat exposures, resulting in increased health risks, heatstroke,
intense, frequent, and prolonged heatwaves [1,2]. Several studies have and even death during heatwave conditions [10–13].
discovered a U-shaped correlation between mortality and ambient Heatstroke, which is characterized by elevated core temperatures, is
temperature [3–5]. The rise in all-cause mortality caused by extreme a fatal disorder resulting from an imbalance in the body’s heat balance
cold and heat has grave public health implications. and dehydration [14]. It is clinically diagnosed when the core temper­
An ageing population presents the globe with a formidable task [6]. ature reaches about 40.6 ◦ C [15]. However, an elevated body temper­
According to the United Nations Population Division’s World Population ature only may not sufficient to diagnose heatstroke. Heatstroke
Prospects (version 2017), the proportion of individuals aged 65 and associated symptoms should also include fatigue, dry skin, nausea,
older will increase quickly from 9.3% in 2020 to 18.9% in 2070 [7]. vomiting, diarrhea, dizziness, reddened face and so on. As the global
Older persons are more vulnerable to heat and cold stimuli than healthy climate warms and exposure to high temperatures rises, the incidence of
adults [8,9] due to reduced physiological functioning including heatstroke among older adults will rise. In 2019, 475 million heatwave

* Corresponding author.
E-mail address: [email protected] (Q. Deng).
1
These authors contributed equally to this work.

https://doi.org/10.1016/j.buildenv.2023.110324
Received 7 February 2023; Received in revised form 13 April 2023; Accepted 16 April 2023
Available online 23 April 2023
0360-1323/© 2023 Elsevier Ltd. All rights reserved.
Y. Ou et al. Building and Environment 237 (2023) 110324

Nomenclature Tcore Core body temperature (◦ C)

Total metabolic rate Total metabolic rate (met)
Symbol Tset set-point temperatures (◦ C)
Act Activity level (met) va Air velocity (m/s)
Cold Output from cold thermoreceptor (◦ C) Vasodilation the onset for cutaneous vasodilation (1⋅h− 1)
Colds Total output from cold thermoreceptor (◦ C) Warm Output from warm thermoreceptor (◦ C)
de Dehydration rate (%) Warms Total output from warm thermoreceptor (◦ C)
i Number of the segment, i α Coefficient (dimensionless)
Maximal sweat maximum sweating (kcal⋅h− 1) β Coefficient (dimensionless)
RH Relative humidity (%) γ Coefficient (dimensionless)
SKINR Weighting coefficient of cold and warm signals received by η Coefficient (dimensionless)
temperature receptors (dimensionless)
Sweat cumulative sweating volume (g) Abbreviations
T Node instantaneous temperature (◦ C) CO Cardiac output
Ta Ambient temperature (◦ C)

occurrences afflicted vulnerable populations around the world, resulting wakening of thermoregulatory functions such as skin blood flow,
in an increase in illness and mortality [16]. The heat-related mortality sweating, vasomotion, no elderly model has considered the impact of
among adults aged 65 and older increased by 53.7% over the past two dehydration on thermoregulatory function impairment. As a result, it is
decades, reaching 296,000 deaths in 2018 [7]. To date, there is no important to develop an elderly model to investigate the impact of
public health guideline on daily heatstroke risks for the public to follow dehydration on the occurrence of heat illnesses such as heatstroke.
in order to safeguard individual health and safety during hot summer Clinical trials often involve safety precautions and cannot be subjected
days and heatwave incidents. Heatstroke risk and efficient preventative to elevated ambient temperatures for extended periods of time. The
measures have not been systematically examined yet. human thermoregulation model is ones of the most accurate approaches
Due to its ease of use as a tool for quantitative research of the human for determining survival time in extreme heatwaves.
thermal response, the human thermoregulation model is frequently Using a newly modified model of elderly thermoregulation that takes
employed for human thermal comfort assessment studies in a variety of into account the effects of dehydration on thermoregulatory functions,
thermal conditions. The body’s heat balance is the basis of human we sought to predict and identify heatstroke in healthy older adults as
thermoregulation, meaning that the body’s heat production must equal early as possible. In this work, adults aged 60 and up with no pre-
its heat loss in order to maintain the body’s heat balance. Various existing conditions or respiratory, cardiovascular, or skin diseases are
models have been constructed to study human thermal comfort and considered healthy older adults. First, based on published physiology
thermophysiological responses in heat and cold exposures [17]. Models studies, the parameters of the young adult thermoregulation model were
range from the Fanger equation-based Predicted Mean Votes model [18] adjusted to account for differences in thermoregulatory capacity be­
to the simple 2-node Gagge model [19] to multi-segment multi-node tween the elderly and healthy young adults. The modified model was
models, such as the 6-segment 25-node Stolwijk model [20], the then validated using publicly available human trial data. Following that,
16-segment 65-node Tanabe model [21], the 15-segment 187-node Fiala the impact of environmental conditions and activity level on the
model [22], and the three-dimensional 15-segment thermoregulatory development of heatstroke in older adults exposed to extreme heat was
models [23,24]. In recent years, a greater emphasis has been placed on thoroughly investigated and compared. Finally, effective heatstroke
individualized models that can predict thermophysiological responses of intervention strategies for the elderly were examined and presented. The
specific populations [25–27]. Diverse detailed models estimate the work presented in this study contributes to the prevention of heat stroke
thermoregulatory response of humans to temperate surroundings, and in healthy older adults during prolonged heat exposure.
hence do not account for the “danger of death” under extreme envi­
ronmental conditions such as extreme heatwaves. There are models that 2. Methods
take dehydration into consideration when forecasting the risk of heat­
stroke in extreme heat situations [14]. Despite this, the thermophysio­ 2.1. Classical human thermoregulatory model
logical reactions of the elderly were not precisely modelled when
healthy adults were used as a proxy. This concern cannot be overlooked: A 6-segment and 25-node human thermoregulatory model developed
the world’s population is rapidly ageing. In extreme weather, the elderly by Stolwijk was employed [20]. The multi-segment multi-node model
groups are more susceptible to extreme temperatures (such as heatwaves divided a man’s body, which weighed 64.9 kg and had a surface area of
and cold spells). However, the majority of existing models of human 1.77 m2, into six segments (head, trunk, arms, hands, legs, and feet),
thermoregulation are based on healthy younger adults and do not ac­ with each segment consisting of four concentric layers (core, muscle, fat,
count for changes in the thermoregulation capability of the aged and skin) and a central blood compartment. The Stolwijk model is a
population. negative feedback regulation model. Utilizing mathematical equations,
The majority of existing thermoregulation models were established the set point theory of physiological temperature regulation statistically
for healthy young adults, with no regard for physiological differences describes the human thermoregulatory mechanism using a negative
between young and old individuals [17,27–30]. The thermoregulatory feedback control system [36]. In the model, each node in human body
capacity of the elderly is noticeably different from that of healthy young has a set point temperature, the difference between the actual temper­
adults as a result of the progressive decline in physiological system ature of each node and the set point temperature generates a control
function associated with ageing [31–34]. Dehydration is the most signal. The hypothalamus comprehensively processes these control sig­
common fluid and electrolyte issue among the elderly [35]. Age-related nals thoroughly before directing them to the thermoeffector, which
changes in total body water, thirst perception, renal concentrating regulate cutaneous vasodilation and sweating (heat stress) or cutaneous
ability, and vasopressin effectiveness all predispose to dehydration. vasoconstriction and shivering (cold stress) to control human body
Whilst existing models have taken into consideration aged-related temperature. During heat exposure, the blood flow first increases due to

2
Y. Ou et al. Building and Environment 237 (2023) 110324

cutaneous vasodilation, resulting in an increase in skin surface heat loss Table 2

to environment. As core temperature rises due to extended exposure to Threshold value differences between healthy younger adults and the elderly.
heat, sweating begins to aid in body heat dissipation to maintain core Thermoregulatory Threshold Younger Older Source
temperature stability. variables control adults (◦ C) adults data
parameter (◦ C)
2.2. Improved human thermoregulatory model Sweating onset Tcore (core 36.90 36.95 [48]
temperature)
To predict the process of core temperature change during high Vasodilation onset Tcore (core 36.80 36.85 [49]
temperature)
temperature exposure in the elderly, we modified the classical Stolwijk Maximum dilatation Tcore (core 37.20 37.25 [50]
thermoregulation model in two ways. The classical thermoregulation temperature)
model was constructed using the set value theory. Numerous in­
vestigations have demonstrated, however, that the set value varies ac­
cording to the core threshold temperature and heat effector gain [37,
38]. On the other hand, the classical thermoregulation model was
established based on healthy young adults. Numerous studies now
demonstrate that, relative to younger persons, ageing degradation af­
fects all aspects of physiology in older adults [38–40]. We researched
and collated prior studies on thermoregulatory models in the elderly
[41–50], and then modified the pertinent physiological parameters of
the traditional thermoregulatory model (e.g., Tables 1 and 2). Aging
slows the initiation of sweating and cutaneous vasodilation, reduces
systemic metabolism (a 30% decrease in basal core metabolic rate and a
20% decrease in basal skin metabolic rate were adopted in our model)
[42,43], and diminishes the maximal capacity for heat sensitivity and
heat loss responses, resulting in a greater rise in body temperature
during heat stress.
The classical thermoregulatory model was based on the set-point
(fixed threshold) concept [38], which meant that the strength of the
efferent signals was determined by comparing the afferent signals to the
set-point temperatures (Tset, see Eqs. (1) and (2)). Existing experimental
studies, however, have discovered that the threshold temperature is not
fixed but varies within a zone [37–39]. In this extended elderly model,
the effect of dehydration (denoted as de) on thermophysiological re­
sponses was also considered, the percentage of water loss due to
sweating to the total body weight (the body weight of a standard older
adult: 64.9 kg) defined in Eq. (3). Fig. 1 depicts the impact of dehy­
dration (de) on the threshold increment in both sweat rate and vasodi­
lation in both healthy younger and older adults (i.e., elderly). Further,
the dehydration (de) could reduce skin blood flow by raising the cuta­
neous vasodilation threshold, as well as impair sweating response by
raising the threshold temperature to induce sweating and lowering
sweating sensitivity [38,51]. The impacts of dehydration on sweating
and vasodilation are described in Eqs. (4) and (5).
The dehydration rate (de), the cumulative sweating volume (Sweat),
the onset for cutaneous vasodilation (Vasodilation), the maximum
sweating and the total metabolic rate in the elderly are calculated using
Fig. 1. Dehydration (de) raises the threshold temperature for sweat rate (a) and
below equations [14]:
cutaneous vasodilation (b) in both healthy younger adults and older adults (the
∑
6 elderly) [14].
If T − Tset > 0, Warm = T − Tset , Warms = Warm × SKINR(i) (1)
i− 1
Sweat = (0.1159 − β × de) × (T − (Tset + α × de)) + 0.0134
∑
6
If T − Tset < 0, Cold = T − Tset , Colds = Cold × SKINR(i) (2) × (Warms − Colds) (4)
i− 1

∫π Vasodilation = 58.5 × (T − (Tset + γ × de)) + 3.75 × (Warms − Colds) (5)

Sweat × dt
de = 0
× 100 (%) (3)
64.9 Maximal sweat = 0.696 − 0.696 × η (6)

Total metabolic rate = 94.42 × Act (7)

Table 1
Age-related weakening of key physiological parameters on the elderly. where, Tset is set-point temperature (i.e., threshold temperature), ◦ C;
Physiological parameter Age-related changes Sources Warms and Colds are integrated signals from the skin thermoreceptors,
◦
C; SKINR(i) is the weighting coefficient of cold and warm signals
Basal metabolic rate (W) − 30% [41–43]
Basal metabolic rate (W) − 19.2% [44] received by temperature receptors in each part of the skin layer, all
Max skin blood flow (cm3/s) − 30% [43,45–47] weighting coefficients are presented in Table S3 of the Supplementary
Sweating factor − 20% [43,48,49] Materials (https://doi.org/10.6084/m9.figshare.20799520.v1), dimen­
Cardiac Output (CO) − 14.4% [44] sionless; Act is activity level in met; The model assumed that 1%

3
Y. Ou et al. Building and Environment 237 (2023) 110324

dehydration (de) elevates thresholds for sweating and cutaneous vaso­

dilation by 0.06 ◦ C and decreases sensitivities for sweating by 0.068 kg/
(hr⋅◦ C) [14]. Coefficients α, β, and γ indicate the increase in sweating
temperature threshold, the decrease in sweating sensitivity and the in­
crease in vasodilatation threshold after each 1% increase in the dehy­
dration rate, respectively. The model also assumes that the threshold
temperatures in all segments are the same. The coefficients α, β, γ, and η
are taken from those published in a previous research study [14]. In this
modified model, we set η = 0.2 based on a number of experiments on the
delayed onset of maximal sweating in the healthy elderly [52–54]. We
set α = 0.06 and β = 0.068 in this modified model based on an inves­
tigation that studied the thermosensitivity of cutaneous blood flow and
sweating in healthy elderly [55]. To ensure a physiological response to
heat stress, γ was set to 0.06 [51,56].

2.3. Heatstroke occurrence time, simulations and validation

The occurrence time of classic heatstroke is defined as the maximum

tolerance time before heatstroke occurs (Tcore = 40.6 ◦ C) during passive
heat exposures.
The complexity of heat transfer within the human body necessitates
that the following assumptions be made in order to arrive at a solution
for temperature distribution. Heat transfer in each segment of the
human body occurs in the radial direction, disregarding the effect of
axial heat transfer by the blood flow; the physical and thermophysio­
logical parameters within each node are uniformly distributed; the
temperature of blood entering the tissue is equal to the temperature of
the central blood compartment, and the temperature of outflowing tis­
sue is equal to the temperature of the tissue. The heat transfer details of
our model’s passive system are depicted in Section 1 (titled 1. Passive
control system) of the Supplementary Materials (https://doi.org/10.60
84/m9.figshare.20799520.v1). Because environmental parameters (air
temperature, relative humidity, air speed, etc.) influence convective,
radiative, and evaporative heat transfer from the body to the sur­
rounding environment via clothing, it is critical to validate the modified
model against human data collected under various environmental con­
Fig. 2. Flow chart of the elderly model sequence of operation.
ditions (see Table 3) [57–59]. In accordance with the experimental
conditions, the ambient temperature, relative humidity, and metabolic
rate were adjusted during validation. For simulations, two extreme 3. Results
heatwave conditions were chosen: an extremely hot humid condition
(Ta = 39 ◦ C, RH = 65%, va = 0.1 m/s, water vapor pressure: 4.6 kPa) and This section is divided into two subsections. The validation results of
an extremely hot dry condition (Ta = 40 ◦ C, RH = 20%, va = 1.0 m/s, the elderly model are presented in subsection 3.1. The purpose of sub­
water vapor pressure: 1.5 kPa). section 3.2 is to demonstrate the effects of temperature, humidity,
airspeed, and activity levels on the thermophysiological responses (Tcore
and sweating rate) of older adults.
2.4. Solution procedure
3.1. Model validation
The computation programme is written using the Compaq Visual
Fortran software. Fig. 2 depicts the sequence of operations for the Fig. 3 illustrates the comparison between the simulated thermo­
modified elderly model flow chart. The modified elderly thermoregu­ physiological responses by the modified elderly thermoregulation model
lation model is described in full in the Supplemental Materials and those of other published clinical trial studies [57–59]. Our results
(https://doi.org/10.6084/m9.figshare.20799520.v1). Air temperature, for core temperature and skin temperature are comparable to those of
relative humidity, air velocity, and clothing insulation were among the previous research (i.e., the maximum Tcore differences: 0.2–0.3 ◦ C). The
boundary condition data (i.e., initial condition). The model assumed aforementioned clinical investigations involving the elderly lasted just
that all individual body segments were covered by homogeneous one to 2 h, hence the succeeding phases of body temperature responses
clothing and were exposed to uniform thermal environments. (e.g., final rapid progression phase due to uncompensable heat stress)
are unknown. However, the core temperature responses exhibited by
Table 3 our modified model during phases 1 and 2 (i.e., thermoregulatory
Environmental parameters used for model validations. equilibrium alignment phase and thermoregulatory steady-state phase)
Simulation Clothing Wind Relative Ambient are in good agreement with experimental findings.
cases and insulation speed humidity temperature
sources (clo) (m/s) (%) (◦ C)
3.2. Effects of temperature, humidity, airspeed and activity levels on
1 [57] 0.03 0.1 80 31 thermophysiological responses
2 [59] 0.03 0.1 60 36.5
3 [58] 0.03 0.1 22 40
The primary determinants of the body temperature of the elderly are

4
Y. Ou et al. Building and Environment 237 (2023) 110324

Fig. 3. Model validation of the modified thermoregulatory model. (a) Mean skin temperatures predicted by the elderly model and experimental data from Xiong
et al. [57]; (b)Mean skin temperature changes predicted by the elderly model and experimental data from Dufour et al. [58]; (c) Core temperature responses
predicted by the elderly model and experimental data from Dufour et al. [58]; (d) Core temperature responses predicted by the healthy younger adult model and
experimental data (elderly) from Dufour et al. [58]; (e) Core temperature responses predicted by the elderly model and experimental data from Stapleton et al. [59].

external conditions (air temperature, relative humidity and wind speed) Fig. 5 illustrates the sweating reactions of healthy young adults and
and physical activity. Using the modified thermoregulatory model the elderly to heat stress. In healthy younger adults, sweating climbed to
mentioned in the Methods section, the researchers examined the impact its maximum level and remained there for some time before declining to
of these characteristics in the development of heatstroke in the elderly. the point where no sweating occurred. The elderly group, on the other
Fig. 4 summarizes the responses of healthy younger people and older hand, perspires more slowly; after the sweating rate reaches its peak, it
adults to an extremely hot humid condition (39 ◦ C & 65%RH) and an drops gradually until it ends. During heat exposure, the elderly group
extremely hot dry condition (40 ◦ C & 20%RH). We discovered that the sweats more slowly and less than healthy younger adults.
core temperature responses for the young adults and the elderly The core temperature responses are substantially affected by envi­
comprised of three distinct phases: During the initial phase, due to the ronmental factors. Fig. 6 illustrates the impact of air temperature and
uncompensated heat load, the core temperature increases slowly and relative humidity on the temporal evolution of core temperature. Ac­
linearly with air temperature. The second phase is the equilibrium cording to the findings, the steeper the first-stage rise in core tempera­
plateau phase, in which the core temperature remains practically con­ ture, the higher the core temperature, the shorter the equilibrium
stant as a result of perspiration. Due to the failure of thermoregulation plateau period, and the sooner the onset of heatstroke. Heatstroke
brought on by dehydration, the third stage is characterized by a rapid occurred in the third stage under conditions of lower air temperature
rise in core temperature. Due to decreased thermoregulation, the core and relative humidity, and the advancement of heatstroke in the elderly
temperature of the elderly was higher than that of the control group of group was substantial when compared to healthy younger adults. In
healthy young adults, resulting in an increase in the first two stages and addition, increased air temperature and relative humidity caused the
an earlier onset of heatstroke. onset of heatstroke in the first stage due to disruptions in

5
Y. Ou et al. Building and Environment 237 (2023) 110324

Fig. 4. Core temperature responses of healthy younger adults and elderly in an extremely hot humid condition (39 ◦ C, RH = 65%, va = 0.1 m/s) and an extremely hot
dry condition (40 ◦ C, RH = 20%, va = 1.0 m/s). Horizontal dash lines denote the heatstroke threshold temperature, i.e., 40.6 ◦ C.

Fig. 5. Temporal variations of sweat rate in both elderly and healthy younger adults in an extremely hot humid condition (39 ◦ C, RH = 65%, va = 0.1 m/s) and an
extremely hot dry condition (40 ◦ C, RH = 20%, va = 1.0 m/s).

thermoregulation, hence reducing the survival time gap between the production rates and delayed sweating hamper body cooling. Lower
elderly group and the healthy younger adult controls. cardiac output and a diminished capacity to redistribute blood from the
Fig. 7 depicts the effects of varying degrees of human activity on the visceral circulation will result in lower skin blood flow in the elderly [39,
onset of heatstroke. The healthy older adults and younger adults both 62,63].
had heatstroke during the initial period of vigorous activity. The elderly Fig. 8 shows the outcomes of our analysis of the effect of each
performed worse at heat dissipation than younger adults during the parameter on the core temperature response. Sweating onset threshold
same level of activity, increasing the risk of heatstroke. temperature directly affects the timing of early and late sweating in the
human body. When the sweating threshold temperature of the human
4. Discussion body rises, the onset of sweating will be delayed, and body heat cannot
be dissipated in a timely manner, leading to a faster rise in core tem­
4.1. Impact of sweating and vasodilation threshold value changes on core perature. The slope of the sweating threshold influences the rate of
temperature sweating; the steeper the slope, the faster the rate of sweating, which can
take away heat from the skin surface more quickly and suppress the
During heat stress, cutaneous vasodilation and sweating are the two increase in core temperature. Similarly, an increase in the vasodilatory
primary heat dissipation mechanisms for maintaining body temperature threshold delays the initiation of vasodilation, and an increase in the
[60,61]. During exposure to extreme heat, enhanced heat loss and vasodilatory slope increases the rate of vasodilation.
decreased heat production (cutaneous vasodilation and sweating) are
activated only when the body temperature surpasses a predefined
4.2. Higher risk of heatstroke in the elderly
threshold. The linear part of the relationship indicates the thermal
sensitivity of the response. Consequently, the onset threshold, heat
Our analysis predicts the occurrence of heat stroke in elderly in­
sensitivity, skin vasodilation, and maximal sweating capacity have a
dividuals exposed to high temperatures. The percentage and absolute
major impact on body heat loss and heat generation during exposure to
quantity of the world’s senior population is rising quickly, and they have
heat. Some bodily functions change with age, resulting in changes in
a high mortality rate in hot climates. When elderly people are subjected
thermoregulation. The elderly groups are less sensitive to variations in
to heatwaves, it is crucial to consider the possibility of heat-related
ambient temperature [8,57], which can lead to an inability to respond
disorders such as heatstroke. However, there is scant evidence linking
appropriately to maintain core temperature. In the elderly, lower sweat
older adults to heatstroke. While the majority of research has

6
Y. Ou et al. Building and Environment 237 (2023) 110324

exposed to heat. The explanation for this is that the older adults have an
impaired sweating response, resulting in a shorter duration of the third
phase and a quick rise in core temperature due to dehydration and
psychological stress [65,66]. During exposure to heat stress, older adults
have greater core temperatures and more rapid increase in core tem­
peratures. This implies that older adults are more sensitive to high
temperatures during heatwaves and experience heatstroke at “lower”
levels of heat stress than healthy younger adults [67–69].
We also investigated the effect of environmental factors (such as air
temperature and relative humidity) on the onset of heatstroke in both
healthy younger and older adults. In many nations with coastal climates,
high temperatures during heatwaves are always accompanied by high
relative humidity. Changes in ambient temperature and relative hu­
midity have a considerable impact on the survival time of both healthy
young individuals and older adults. It has been demonstrated that the
temperature and relative humidity have a synergistic effect on heat-
related illnesses [70,71]. It is evident that older adults exhibit greater
core temperatures and shorter survival time in a variety of
high-temperature or high-relative-humidity conditions, which is
consistent with a higher mortality rate among older individuals during
heatwaves [72–75].

4.3. Heatstroke prevention measures for the elderly

Older adults are more sensitive to heat and cold than their younger
counterparts. They are, however, less thermosensitive to environmental
changes and adapt less effectively to heat and cold exposure, implying
that older adults are at a higher risk of heatstroke and even death from
any cause during extreme heatwaves [76]. It is thus crucial for older
adults to adopt effective measures to decrease core temperature rise and
avoid heat-related diseases or heatstroke during extreme weather
events. The prevention of classic heatstroke in older adults can be ach­
ieved in four ways: environmental condition management (e.g., using
air conditioning), hydration (consuming fluids), heat acclimatization,
less use or non-use of drugs that partially alter thermoregulation, and
the use of personal cooling systems (using electric fans, wearing cooling
vests, etc.) [77–82].
Controlling environmental parameters involves adjusting the tem­
perature and relative humidity of the surrounding environment. As
depicted in Fig. 6(a)-6(c), reducing both the ambient temperature and
relative humidity is advantageous for reducing core temperature.
Consequently, during an extreme heatwave incident, older adults should
seek refuge in a location with more controlled and appropriate envi­
ronmental parameters such as air-conditioned rooms.
The elderly should receive hydration not only when they are thirsty,
but also on a daily basis. Because the older adults are less sensitive to
Fig. 6. Effect of air temperature (a) and relative humidity (b & c) on core
heat and have a higher sweating threshold, it is probable that they will
temperature responses during extreme heat exposures at 39 ◦ C and 40 ◦ C.
endure more variations in core temperature without experiencing thirst.
The elderly individuals are at a high risk of getting heat-related ailments
concentrated on physiological factors such as cutaneous blood flow and or perhaps dying from heatstroke in this situation. As seen in Fig. 9(a)
perspiration response to heat stress, the body core temperature of older and (b), hydration can effectively enhance the sweating rate while
persons has received very less attention. Maintaining a core body tem­ decreasing the rise in core temperature. In addition, consuming cold
perature between 36.5 ◦ C and 38.5 ◦ C is essential for the body’s integrity water/beverages and ice slurry can aid in rapidly reducing core tem­
and regular operation. A core body temperature of higher than 41.5 ◦ C perature [84–87].
or less than 33.5 ◦ C causes a rapid loss of normal physiological function, Acclimatization to heat induces thermoregulatory adaptation (e.g.,
which can lead to injury and death [64]. Xiong et al. [57] investigated enhanced sweating function) in the older adults [82,88,89]. As depicted
the perceptual and physiological responses of the elderly to varying in Fig. 9(c), an enhancement in the sweating function due to heat
temperatures, however the experiment lasted just 60 min. Unknown is acclimatization can effectively prevent the core temperature from rising.
the temporal progression of core temperature at the onset of heatstroke Tcore was evidently suppressed by 1.3 h due to exercise habits to reach
in the elderly. Our findings reveal a three-stage change in the core body the heatstroke threshold (i.e., Tcore = 40.6 ◦ C).
temperature of elderly individuals exposed to high temperatures, indi­ Multiple drugs may cause diuretic and electrolyte imbalance,
cating a greater risk of heatstroke compared to healthy younger adults. drowsiness and cognitive impairment, altered thermoregulation,
We studied the temporal evolution of core temperature between impaired detection of thirst, decreased sweating, hypotension, and
healthy and older adults. Both elderly and healthy younger adults had a decreased cardiac output in older adults [90–92]. In addition to
three-stage change in core body temperature, whereas older adults restricting their use, proper hydration and exercise can help prevent
displayed greater core temperatures and lower survival durations when heatstroke. During a heatwave incident, an increase in cardiac output

7
Y. Ou et al. Building and Environment 237 (2023) 110324

Fig. 7. Effect of metabolic rate on core temperature responses during heat exposures at 39 ◦ C and 40 ◦ C. ACT is the metabolic rate in met. The metabolic rate values
in met are represented by the numbers 1, 2, and 3. Horizontal dash lines denote the heatstroke threshold temperature, i.e., 40.6 ◦ C.

Fig. 8. Effects of sweating slope change (a), sweating onset threshold change (b), vasodilatation threshold change (c) and vasodilatation slope change (d) on core
temperature responses at 39 ◦ C, RH = 65% and 0.1 m/s air speed. Horizontal dash lines denote the heatstroke threshold temperature, i.e., 40.6 ◦ C.

can improve blood flow to the skin, thereby aiding in body heat dissi­ energy was wasted in hot conditions [96,97]. To balance heat storage in
pation. As depicted in Fig. 9(d), a decrease in the cardiac output accel­ extreme heat, high cooling power personal cooling systems are neces­
erates the ascent of core temperature, rendering older adults more sary. However, this presents a significant challenge to cooling system
susceptible to heatstroke. developers in this era of energy crises.
Personal cooling technologies, such as a water-cooling vest, have
demonstrated their potential effectiveness in mitigating heat stress 5. Limitations
while exposed to hot conditions in a short duration (1–2 h) [93–95]. It
should be mentioned that such personal cooling devices absorb heat This study has some limitations. The extended elderly model was
from the surrounding hot environment, reducing their efficiency. A prior validated using data from short-duration heat exposures that were pre­
numerical research study revealed that more than half of the cooling viously published. The rapid progression in core temperature due to

8
Y. Ou et al. Building and Environment 237 (2023) 110324

Fig. 9. Various heatstroke alleviation measures and their effects on core temperature and sweating responses. The model assumed that there would be no fluid intake
during the heat exposure to prevent dehydration. (a) Core temperature responses after drinking 500 ml water; b) Sweating responses after drinking 500 ml water
(simulations were performing by adjusting the dehydration rate [i.e., the ratio of mass of water consumed to the real time body weight]); c) Impact of improved
exercise-induced sweating function (by adjusting the maximum sweating rate to match that of younger adults) on heatstroke prevention [83]; d) The role of altered
cardiac output in the prevention of heatstroke. Horizontal dash lines denote the heatstroke threshold temperature, i.e., 40.6 ◦ C.

uncompensable heat stress caused by dehydration and psychological in an extremely hot and dry environment (40 ◦ C, 20%RH, va = 1.0 m/s)
stress in the elderly has not been validated. Nonetheless, a recent 14-h [98]. Furthermore, only a few validations of the mean skin temperature
prolonged heat exposure on healthy young individuals demonstrated are presented, and more work should be done in the future to thoroughly
the existence of the rapid development stage after 8–9 h of heat exposure validate both Tcore and Tsk. Next, the passive system in our model only

9
Y. Ou et al. Building and Environment 237 (2023) 110324

considered elderly groups wearing minimal clothing, and the impact of Acknowledgments
different clothing levels on thermophysiological responses should be
considered in future work. Furthermore, the effect of body movement on The study was supported by the National Natural Science Foundation
heat transfer (passive system) and thermoregulation (active system) is of China (No. 41977369).
overlooked. Such a limitation should also be considered in the future
model as well. In addition, the impact of personal cooling system on Appendix A. Supplementary data
heatstroke prevention has not been examined. Previous studies
demonstrated that the use of personal cooling systems helped alleviate Supplementary data to this article can be found online at https://doi.
heat stress for a range of populations, including laborers, firefighters, org/10.1016/j.buildenv.2023.110324.
farmers, troops, and office staff working in hot environments. The
elderly groups are anticipated to have a lower level of physical activity References
than younger counterparts. Their metabolic heat production is conse­
quently lower than that of younger adults. This may reduce their cooling [1] A.L. Braga, A. Zanobetti, J. Schwartz, The time course of weather-related deaths,
Epidemiology 12 (6) (2001) 662–667.
requirement for a powerful personal cooling system, increasing their [2] M. Medina-Ramon, A. Zanobetti, D.P. Cavanagh, J. Schwartz, Extreme
options for different types of personal cooling systems to combat heat temperatures and mortality: assessing effect modification by personal
stress during heatwaves. Future research is required to address the characteristics and specific cause of death in a multi-city case-only analysis,
Environ. Health Perspect. 114 (9) (2006) 1331–1336.
above limitations. [3] M. Medina-Ramon, J. Schwartz, Temperature, temperature extremes, and
mortality: a study of acclimatisation and effect modification in 50 US cities, Occup.
6. Conclusions Environ. Med. 64 (12) (2007) 827–833.
[4] G.A. Meehl, C. Tebaldi, More intense, more frequent, and longer lasting heat waves
in the 21st century, Science 305 (5686) (2004) 994–997.
We modified the classical multi-segment, multi-node human ther­ [5] T.R. Karl, A. Arguesz, B. Huang, J.H. Lawrimore, J.R. McMahon, M.J. Menne, T.
moregulation model to account for the elderly’s increased vasodilata­ C. Peterson, R.S. Vose, H.M. Zhang, Climate change. Possible artifacts of data
biases in the recent global surface warming hiatus, Science 348 (6242) (2015)
tion and sweating thresholds, as well as reduced thermal sensitivity,
1469–1472.
reduced maximal sweating capacity and lowered metabolic rate. The [6] United Nations, World population prospects: 2017 Revision [accessed on May 10,
hallmark of our work is that it examines the thermoregulatory properties 2022], https://www.un.org/development/desa/publications/world-population
of the aged population using a revised thermoregulatory model for high -prospects-the-2017-revision.html.
[7] N. Watts, et al., The 2020 report of the Lancet Countdown on health and climate
temperatures. Aging increases the sweating threshold temperature and change: responding to converging crises, Lancet 397 (10269) (2021) 129–170.
subcutaneous vasodilatory activity, reduces the sensitivity of skin [8] G.S. Anderson, G.S. Meneilly, I.B. Mekjavic, Passive temperature lability in the
vasodilation and sweating, resulting in decreased skin blood flow, and elderly, Eur. J. Appl. Physiol. Occup. Physiol. 73 (3–4) (1996) 278–286.
[9] J.M. Waller, H.I. Maibach, Age and skin structure and function, a quantitative
reduces the metabolism and sweating rates. During heat stress, cuta­ approach (I): blood flow, pH, thickness, and ultrasound echogenicity, Skin Res.
neous blood flow and sweating response are the two primary means of Technol. 11 (4) (2005) 221–235.
dissipating heat from the heart to the external environment. The ageing [10] K.J. Collins, A.N. Exton-Smith, C. Dore, Urban hypothermia: preferred temperature
and thermal perception in old age, Br. Med. J. 282 (6259) (1981) 175–177.
of human tissues and organs results in a loss in heat dissipation capa­ [11] Y. Yochihara, T. Ohnaka, Y. Nagai, T. Tokuda, Y. Kawashima, Physiological
bility, which accelerates the rise in core temperature and, eventually, responses and thermal sensations of the elderly in cold and hot environments,
the beginning of heatstroke. The majority of research to far has focused J. Therm. Biol. 18 (5–6) (1993) 355–361.
[12] S. Hajat, W. Bird, A. Haines, Cold weather and GP consultations for respiratory
on thermal comfort studies for the elderly. However, little attention has conditions by elderly people in 16 locations in the UK, Eur. J. Epidemiol. 19 (10)
been paid to the core temperature of older adults in hot situations, such (2004) 959–968.
as heatwaves. Our findings indicate that the modified human thermo­ [13] S. Vandentorren, P. Bretin, A. Zeghnoun, L. Mandereau-Bruno, A. Croisier,
C. Cochet, J. Ribéron, I. Siberan, B. Declercq, M. Ledrans, August 2003 heat wave
regulatory models may accurately predict the temporal development of
in France: risk factors for death of elderly people living at home, Eur. J. Publ.
heatstroke in elderly individuals. The modified thermoregulatory model Health 16 (6) (2006) 583–591.
also shows that human characteristics such as air conditioning use, [14] Q. Deng, J. Zhao, W. Liu, Y. Li, Heatstroke at home: prediction by
water intake, heat acclimatization, medication use, etc., and environ­ thermoregulation modeling, Build. Environ. 137 (2018) 147–156.
[15] Y. Epstein, R. Yanovich, Heatstroke. N Engl J Med. 380 (2019) 2449–2459.
mental conditions have a significant influence in the occurrence of [16] W. Cai, C. Zhang, H.P. Suen, et al., The 2020 China report of the Lancet countdown
heatstroke and gives a reliable way for predicting heatstroke during on health and climate change, Lancet Public Health 6 (2021) E64–E81.
heatwave incidents. Our findings have significant public health ramifi­ [17] K. Katić, R. Li, W. Zeiler, Thermophysiological models and their applications: a
review, Build. Environ. 106 (2016) 286–300.
cations for the prevention of heatstroke in older adults exposed to [18] P.O. Fanger, Thermal Comfort: Analysis and Applications in Environmental
extreme heat. Engineering. Thermal Comfort Analysis & Applications in Environmental
Engineering, 1972.
[19] A.P. Gagge, J.A.J. Stolwijk, Y. Nishi, An effective temperature scale based on a
CRediT authorship contribution statement simple model of human physiological regulatory response, Build. Eng. 77 (1)
(1971) 21–36.
Yinping Ou: Writing – original draft, Formal analysis, Data curation, [20] J.A. Stolwijk, A Mathematical Model of Physiological Temperature Regulation in
Man, NASA, Langley, 1971.
Conceptualization. Faming Wang: Writing – review & editing, Writing – [21] S.I. Tanabe, K. Kobayashi, J. Nakano, Y. Ozeki, M. Konishi, Evaluation of thermal
original draft, Validation, Supervision. Jinping Zhao: Writing – review comfort using combined multi-node thermoregulation (65MN) and radiation
& editing, Formal analysis, Data curation, Conceptualization. Qihong models and computational fluid dynamics (CFD), Energy Build. 34 (6) (2002)
637–646.
Deng: Writing – review & editing, Writing – original draft, Validation,
[22] D. Fiala, K.J. Lomas, M. Stohrer, Computer prediction of human thermoregulatory
Supervision, Methodology, Data curation, Conceptualization. and temperature responses to a wide range of environmental conditions, Int. J.
Biometeorol. 45 (3) (2001) 143–159.
[23] Z. Kang, F. Wang, Udayraj, An advanced three-dimensional thermoregulation
Declaration of competing interest
model of the human body: development and validation, Int. Commun. Heat Mass
Tran. 107 (2019) 34–43.
The authors declare that they have no known competing financial [24] A. Joshi, F. Wang, Z. Kang, B. Yang, D. Zhao, A three-dimensional
interests or personal relationships that could have appeared to influence thermoregulatory model for predicting human thermophysiological responses in
various thermal environments, Build. Environ. 207 (2022), 108506.
the work reported in this paper. [25] A. Coccarelli, H.M. Hasan, J. Carson, D. Parthimos, P. Nithiarasu, Influence of
ageing on human body blood flow and heat transfer: a detailed computational
Data availability modelling study, Int J Numer Method Biomed Eng 34 (10) (2018), e3120.
[26] T. Ma, J. Xiong, Z. Lian, A human thermoregulation model for the Chinese elderly,
J. Therm. Biol. 70 (Pt A) (2017) 2–14.
Data will be made available on request.

10
Y. Ou et al. Building and Environment 237 (2023) 110324

[27] M. Itani, N. Ghaddar, K. Ghali, A. Laouadi, Bioheat modeling of elderly and young [61] J.M. Johnson, D.W. Proppe, Cardiovascular adjustments to heat stress, in:
for prediction of physiological and thermal responses in heat-stressful conditions, C. Blatteis, M. Fregly (Eds.), Handbook of Physiology: Adaptations to the
J. Therm. Biol. 88 (2020), 102533. Environment, American Physiological Society, Bethesda, MD, 1996, pp. 215–243.
[28] D. Fiala, Dynamic Simulation of Human Heat Transfer and Thermal Comfort, De [62] W.L. Kenney, D.H. Craighead, L.M. Alexander, Heat waves, aging, and human
Montfort University, Leicester, 1998. cardiovascular health, Med. Sci. Sports Exerc. 46 (10) (2014) 1891–1899.
[29] D. Fiala, K.J. Lomas, M. Stohrer, A computer model of human thermoregulation for [63] D. Gagnon, S.A. Romero, H. Ngo, S. Sarma, W.K. Cornwell 3rd, P.Y.S. Poh,
a wide range of environmental conditions: the passive system, J. Appl. Physiol. 87 D. Stoller, B.D. Levine, C.G. Crandall, Volume loading augments cutaneous
(5) (1999) 1957–1972. vasodilatation and cardiac output of heat stressed older adults, J. Physiol. 595 (20)
[30] J. Malchaire, A. Piette, B. Kampmann, P. Mehnert, H. Gebhardt, G. Havenith, (2017) 6489–6498.
E. den Hartog, I. Holmér, K. Parsons, G. Alfano, B. Griefahn, Development and [64] D.S. Moran, L. Mendal, Core temperature measurement: methods and current
validation of the predicted heat strain model, Ann. Occup. Hyg. 45 (2) (2001) insights, Sports Med. 32 (14) (2002) 879–885.
123–135. [65] J.A. Bouwknecht, B. Olivier, R.E. Paylor, The stress-induced hyperthermia
[31] J. Larose, P. Boulay, H.E. Wright-Beatty, R.J. Sigal, S. Hardcastle, G.P. Kenny, Age- paradigm as a physiological animal model for anxiety: a review of pharmacological
related differences in heat loss capacity occur under both dry and humid heat stress and genetic studies in the mouse, Neurosci. Biobehav. Rev. 31 (1) (2007) 41–59.
conditions, J. Appl. Physiol. 117 (1) (2014) 69–79. [66] T. Oka, K. Oka, T. Hori, Mechanisms and mediators of psychological stress-induced
[32] W.L. Kenney, T.A. Munce, Invited review: aging and human temperature rise in core temperature, Psychosom. Med. 63 (3) (2001) 476–486.
regulation, J. Appl. Physiol. 95 (6) (2003) 2598–2603. [67] S. Howard, G. Krishna, How hot weather kills: the rising public health dangers of
[33] S.R. Notley, M.P. Poirier, S.G. Hardcastle, A.D. Flouris, P. Boulay, R.J. Sigal, G. extreme heat, BMJ 387 (2022) o1741.
P. Kenny, Aging impairs whole-body heat loss in women under both dry and humid [68] H. Khraishah, B. Alahmad, R.L. Ostergad Jr., A. AlAshqar, M. Albaghdadi, et al.,
heat stress, Med. Sci. Sports Exerc. 49 (11) (2017) 2324–2332. Climate change and cardiovascular disease: implications for global health, Nat.
[34] L. Ji, A. Laouadi, L. Wang, M.A. Lacasse, Development of a bioheat model for older Rev. Cardiol. 19 (2022) 798–812.
people under hot and cold exposures, Build. Simulat. 15 (2022) 1815–1829. [69] M.G.M.O. Rikkert, R.J.F. Melis, J.A.H.R. Claassen, Heat waves and dehydration in
[35] R.J. Lavizzo-Mourey, Dehydration in the elderly: a short review, J. Natl. Med. the elderly, BMJ 339 (2009) b2663.
Assoc. 79 (10) (1987) 1033–1038. [70] A.M. Donoghue, M.J. Sinclair, G.P. Bates, Heat exhaustion in a deep underground
[36] A.A. Romanovsky, Thermoregulation: some concepts have changed. Functional metalliferous mine, Occup. Environ. Med. 57 (3) (2000) 165–174.
architecture of the thermoregulatory system, Am. J. Physiol. Regul. Integr. Comp. [71] W.L. Kenney, D.W. DeGroot, L.A. Holowatz, Extremes of human heat tolerance: life
Physiol. 292 (1) (2007) R37–R46. at the precipice of thermoregulatory failure, J. Therm. Biol. 29 (7–8) (2004)
[37] I.B. Mekjavic, O. Eiken, Contribution of thermal and nonthermal factors to the 479–485.
regulation of body temperature in humans, J. Appl. Physiol. 100 (6) (2006) [72] M. Lye, A. Kamal, Effects of a heatwave on mortality-rates in elderly inpatients,
2065–2072. Lancet 309 (1977) 529–531.
[38] M. Cabanac, Adjustable set point: to honor Harold T. Hammel, J. Appl. Physiol. [73] J. Cheng, Z. Xu, H. Bambrick, H. Su, S. Tong, W. Hu, Heatwave and elderly
100 (4) (2006) 1338–1346. mortality: an evaluation of death burden and health costs considering short-term
[39] C.T. Minson, S.L. Wladkowski, A.F. Cardell, J.A. Pawelczyk, W.L. Kenney, Age mortality displacement, Environ. Int. 115 (2018) 334–342.
alters the cardiovascular response to direct passive heating, J. Appl. Physiol. 84 (4) [74] J. Díaz, A. Jordán, R. García, et al., Heat waves in Madrid 1986–1997: effects on
(1998) 1323–1332. the health of the elderly, Int. Arch. Occup. Environ. Health 75 (2002) 163–170.
[40] Y. Inoue, T. Kuwahara, T. Araki, Maturation-and aging-related changes in heat loss [75] Y. Guo, et al., Heat wave and mortality: a multicountry, multicommunity study,
effector function, J. Physiol. Anthropol. Appl. Hum. Sci. 23 (6) (2004) 289–294. Environ. Health Perspect. 125 (2017), 087006.
[41] K. Tsuzuki, T. Iwata, Thermal comfort and thermoregulation for elderly people [76] Z. Xu, et al., Impact of heatwave on mortality under different heatwave definitions:
taking light exercise, Proc Indoor Air 4 (2002) 647–652. a systematic review and meta-analysis, Environ. Int. 89–90 (2016) 193–203.
[42] D.T. Novieto, Y. Zhang, Towards thermal comfort prediction for the older [77] A. Bouchama, J.P. Knochel, Heat stroke, N. Engl. J. Med. 346 (2002) 1978–1988.
population: a review of aging effect on the human body, IESD PhD Conf Energ [78] T. Hifumi, Y. Kondo, K. Shimizu, Y. Miyake, Heat stroke, J Intensive Care 6 (2018)
Sustain Develop (2010) 35–48. 30.
[43] M. Rida, N. Ghaddar, K. Ghali, J. Hoballah, Elderly bioheat modeling: changes in [79] Y.K. Chan, M. Mamat, Management of heat stroke, Trends Anaesth Crit Care 5
physiology, thermoregulation, and blood flow circulation, Int. J. Biometeorol. 58 (2015) 65–69.
(9) (2014) 1825–1843. [80] B. Muniz-Pardos, et al., Ethical dilemas and validity issues related to the use of new
[44] D.T. Novieto, Adapting a Human Thermoregulation Model for Predicting the cooling technologies and early recognition of exertional heat illness in sport, BMJ
Thermal Response of Older Persons, De Montfort University, Leicester, 2013. Open Exerc Med 7 (2021), e001041.
[45] L.A. Holowatz, W.L. Kenney, Peripheral mechanisms of thermoregulatory control [81] F. Wang, W. Song, An investigation of thermophysiological responses of human
of skin blood flow in aged humans, J. Appl. Physiol. 109 (5) (2010) 1538–1544. while using four personal cooling strategies during heatwaves, J. Therm. Biol. 70
[46] W.L. Kenney, G. Havenith, Heat stress and age: skin blood flow and body (2017) 37–44.
temperature, J. Therm. Biol. 18 (5–6) (1993) 341–344. [82] S.R. Notley, R.D. Meade, A.P. Akerman, M.P. Poirier, P. Boulay, R.J. Sigal, A.
[47] G.A. Rooke, M.V. Savage, G.L. Brengelmann, Maximal skin blood flow is decreased D. Flouris, G.P. Kenny, Evidence for age-related differences in heat acclimatisation
in elderly men, J. Appl. Physiol. 77 (1) (1994) 11–14. responsiveness, Exp. Physiol. 105 (2020) 1491–1499.
[48] S. Sagawa, K. Shiraki, M.K. Yousef, K. Miki, Sweating and cardiovascular responses [83] M.J. Buono, B.K. McKenzie, F.W. Kasch, Effects of ageing and physical training on
of aged men to heat exposure, J. Gerontol. 43 (1) (1988) M1–M8. the peripheral sweat production of the human eccrine sweat gland, Age Ageing 20
[49] W. Karaki, N. Ghaddar, K. Ghali, K. Kalev, I. Holmér, L.L. Vanggaard, Human (6) (1991) 439–441.
thermal response with improved AVA modeling of the digits, Int. J. Therm. Sci. 67 [84] J. Ng, J.E. Wingo, P.A. Bishop, J.C. Casey, E.K. Aldrich, Ice slurry ingestion and
(2013) 41–52. physiological strain during exercise in non-compensable heat stress, Aerosp Med
[50] A. Hirata, T. Nomura, I. Laakso, Computational estimation of decline in sweating in Hum Perform 89 (5) (2018) 434–441, 2018.
the elderly from measured body temperatures and sweating for passive heat [85] M. Nakamura, D. Nakamura, M. Yasumatsu, H. Takahashi, Effect of ice slurry
exposure, Physiol. Meas. 33 (8) (2012) 51–60. ingestion on core temperature and blood pressure response after exercise in a hot
[51] K.K. Kraning, R.R. Gonzalez, A mechanistic computer simulation of human work in environment, J. Therm. Biol. 98 (2021), 102922.
heat that accounts for physical and physiological effects of clothing, aerobic fitness, [86] O. Jay, N.B. Morris, Does cold water or ice slurry ingestion during exercise elicit a
and progressive dehydration, J. Therm. Biol. 22 (4–5) (1997) 331–342. net body cooling effect in the heat? Sports Med. 48 (Suppl 1) (2018) 17–29.
[52] K.G. Foster, F.P. Ellis, C. Doré, A.N. Exton-Smith, J.S. Weiner, Sweat responses in [87] J.K.W. Lee, Z.W. Yeo, A.Q.X. Nio, A.C.H. Koh, Y.S. Teo, L.F. Goh, P.M.S. Tan,
the aged, Age Ageing 5 (2) (1976) 91–101. C. Byrne, Cold drink attenuates heat strain during work-rest cycles, Int. J. Sports
[53] Y. Inoue, M. Shibasaki, H. Ueda, H. Ishizashi, Mechanisms underlying the age- Med. 34 (12) (2013) 1037–1042.
related decrement in the human sweating response, Eur. J. Appl. Physiol. Occup. [88] Y. Inoue, G. Havenith, W.L. Kenny, J.L. Loomis, E.R. Buskirk, Exercise- and
Physiol. 79 (2) (1999) 121–126. methylcholine-induced sweating responses in older and younger men: effect of
[54] R.K. Anderson, W.L. Kenney, Effect of age on heat-activated sweat gland density heat acclimation and aerobic fitness, Int. J. Biometeorol. 42 (4) (1999) 210–216.
and flow during exercise in dry heat, J. Appl. Physiol. 63 (3) (1987) 1089–1094. [89] N. Gerrett, T. Amano, Y. Inoue, N. Kondo, The sweat glands’ maximum ion
[55] S.J. Montain, W.A. Latzka, M.N. Sawka, Control of thermoregulatory sweating is reabsorption rates following heat acclimation in healthy older adults, Exp. Physiol.
altered by hydration level and exercise intensity, J. Appl. Physiol. 79 (5) (1995) 106 (1) (2020) 302–315.
1434–1439. [90] K. Westaway, O. Frank, A. Husband, A. McClure, R. Shute, S. Edwards, J. Curtis,
[56] S.M. Fortney, C.B. Wenger, J.R. Bove, E.R. Nadel, Effect of hyperosmolality on D. Rowett, Medicines can affect thermoregulation and accentuate the risk of
control of blood flow and sweating, J. Appl. Physiol. Respir. Environ. Exerc. dehydration and heat-related illness during hot weather, J. Clin. Pharm.
Physiol. 57 (6) (1984) 1688–1695. Therapeut. 40 (2015) 363–367.
[57] J. Xiong, T. Ma, Z. Lian, R. de Dear, Perceptual and physiological responses of [91] J.B. Layton, W. Li, J. Yuan, J.P. Gilman, D.B. Horton, S. Setoguchi, Heatwaves,
elderly subjects to moderate temperatures, Build. Environ. 156 (2019) 117–122. medications, and heat-related hospitalization in older Medicare beneficiaries with
[58] A. Dufour, V. Candas, Ageing and thermal responses during passive heat exposure: chronic conditions, PLoS One 15 (12) (2020), e0243665.
sweating and sensory aspects, Eur. J. Appl. Physiol. 100 (1) (2007) 19–26. [92] M.L.S. Cuddy, The effects of drugs on thermoregulation, AACN Clin Issues 15 (2)
[59] J.M. Stapleton, J. Larose, C. Simpson, A.D. Flouris, R.J. Sigal, G.P. Kenny, Do older (2004) 238–253.
adults experience greater thermal strain during heat waves? Appl. Physiol. Nutr. [93] F. Wang, C.S.W. Chow, Q. Zheng, Y. Ke, B. Yang, X. Zheng, N. Noor, Q. Zhang,
Metabol. 39 (3) (2014) 292–298. C. Zhang, Y. Zhou, On the use of personal cooling suits to mitigate heat strain of
[60] N. Charkoudian, Skin blood flow in adult human thermoregulation: how it works, mascot actors in a hot and humid environment, Energy Build. 205 (2019), 109561.
when it does not, and why, Mayo Clin. Proc. 78 (5) (2003) 603–612.

11
Y. Ou et al. Building and Environment 237 (2023) 110324

[94] C. Gao, K. Kuklane, F. Wang, I. Holmér, Personal cooling with phase change [97] Udayraj, F. Wang, W. Song, Y. Ke, P. Xu, C.S.W. Chow, Z. Noor, Performance
materials to improve thermal comfort from a heat wave perspective, Indoor Air 22 enhancement of hybrid personal cooling clothing in a hot environment: PCM
(2012) 523–530. cooling energy management with additional insulation, Ergonomics 62 (2019)
[95] O. Jay, et al., Reducing the health effects of hot weather and heat extremes: from 928–939.
personal cooling strategies to green cities, Lancet 398 (10301) (2021) 709–724. [98] F. Wang, Q. Deng, T.H. Lei, X. Wang, A.R. Wang, Biophysical modelling predicts
[96] X. Wan, F. Wang, Udayraj, Numerical analysis of cooling effect of hybrid cooling unreliable core temperature responses on healthy older adults using electric fans at
clothing incorporated with phase change material (PCM) packs and air ventilation residential homes during heatwaves, Build. Environ. 228 (2023), 109888.
fans, Int. J. Heat Mass Tran. 126 (2018) 636–648.

12